WHI Staging and Treatment (16156 - Activated, Traditional)

WHI Form 348 – LILAC Leukemia Abstraction Form Ver. 1VCCC Coder ID: ______Member ID: __ __ - ______- __ Case #: ______CCC ID: ______Other Case #s: ______Date completed: __ __ /__ __ / __ __ (MM/DD/YY) Histology: ______C42.0 _____ (blood) or C42.1 _____ (bone/bone marrow)1. Was any cancer-directed surgery done as part of primary treatment?1 Yes 0 No9 Unknown if cancer-directed surgery performed Go to Question 2 (e.g., death certificate ONLY)1.1 Type of surgery: (Mark all that apply.)1 Splenectomy8 Other surgery (Specify): ______1.2 Surgery Date: __ __ /__ __ /__ __ 1 Exact 2 Estimated 9 Unknown Month Day Year2. Was molecular testing documented in the medical records as part of the initial work-up?1 Yes 0 No2 Recommended, unknown if done Go to Question 39 Unknown 2.1 Test type: (Mark all that apply.)1 Bone marrow biopsy 4 FISH2 Peripheral blood 8 Other (Specify): 3 Conventional Karyotype 3. Was chemotherapy, immune-modulating, or targeted therapy administered as part of the first course of therapy?1 Yes 0 No2 Recommended, unknown if done Go to Question 4.9 Unknown 3.1 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownAdministration route: 1 Oral 8 Other: ______R:\DOC\EXT2\FORMS\ALL STUDY\LILAC\CURRENT\F348V1.DOC Pg. 1 of 4 7/20/17 WHI Form 348 – LILAC Leukemia Abstraction Form Ver. 1V(Mark all that apply.) 2 IV 9 Unknown 3.2 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownAdministration route: 1 Oral 8 Other: ______(Mark all that apply.) 2 IV 9 Unknown 3.3 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownAdministration route: 1 Oral 8 Other: ______(Mark all that apply.) 2 IV 9 Unknown 3.4 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownAdministration route: 1 Oral 8 Other: ______(Mark all that apply.) 2 IV 9 Unknown 3.5 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownAdministration route: 1 Oral 8 Other: ______(Mark all that apply.) 2 IV 9 Unknown 3.6 Regimen Name: Code: Start date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year __ __ / __ __ / __ __ End date: 1 Exact 2 Estimated Month Day Year 3 Continued use 9 UnknownR:\DOC\EXT2\FORMS\ALL STUDY\LILAC\CURRENT\F348V1.DOC Pg. 2 of 4 7/20/17 WHI Form 348 – LILAC Leukemia Abstraction Form Ver. 1VAdministration route: 1 Oral 8 Other: ______(Mark all that apply.) 2 IV 9 Unknown 4. Was radiation therapy given as part of the first course of therapy? 1 Yes 0 No2 Recommended, unknown if done Go to Question 5.9 Unknown4.1 What type of radiation was administered? (Mark all that apply.)1 External beam radiation therapy (EBRT) at tumor site8 Other (Specify): ______9 Unknown4.2 Start date: __ __ /__ __ /__ __ 1 Exact 2 Estimated 9 Unknown Month Day Year Stop date: __ __ /__ __ /__ __ 1 Exact 2 Estimated 9 Unknown Month Day Year Total dosage of radiation received: ______cGy/Rad 9 Unknown4.3 Site irradiated: 9 Unknown5. Was endocrine-targeted/hormone therapy given?1 Yes 0 No2 Recommended, unknown if done Go to Question 3.9 Unknown5.1 Agent Name: Code: ______Use: 1 Intermittent use 2 Continuous use 9 UnknownStart date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day YearEnd date or last documented use: __ __ / __ __ / __ __ 1 Exact 2 Estimated Month Day Year 3 Current use 9 Unknown5.2 Agent Name: Code: ______R:\DOC\EXT2\FORMS\ALL STUDY\LILAC\CURRENT\F348V1.DOC Pg. 3 of 4 7/20/17 WHI Form 348 – LILAC Leukemia Abstraction Form Ver. 1VUse: 1 Intermittent use 2 Continuous use 9 UnknownStart date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day YearEnd date or last documented use: __ __ / __ __ / __ __ 1 Exact 2 Estimated Month Day Year 3 Current use 9 Unknown 6. Were other treatments administered?1 Yes 0 No Go to Question 7.9 Unknown6.1 Type of treatment1 Bone marrow transplant 3 Watchful waiting/Surveillance2 Stem cell transplant 8 Other (Specify): 7. Has the participant ever been disease-free since the initial diagnosis/treatment? Yes 1 7.1 Date as documented in the medical records*: __ __ / __ __ / __ __ Month Day Year 0 No9 Unknown* If no evidence of new, evolved or recurrent disease: Record most recent documented disease-free date. If documented new, evolved or recurrent disease: Record first known disease-free date, if one exists.8. Was there a new, evolved or recurrent leukemia diagnosed? Code whether or not a disease-free interval exists.1 Yes 0 No 9 Unknown8.1 Histology: 1 Same disease process 2 Different disease process 9 Unknown Specify histology: Diagnosis date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day Year8.2 Histology: 1 Same disease process 2 Different disease process 9 Unknown Specify histology: Diagnosis date: __ __ / __ __ / __ __ 1 Exact 2 Estimated 9 Unknown Month Day YearComments: R:\DOC\EXT2\FORMS\ALL STUDY\LILAC\CURRENT\F348V1.DOC Pg. 4 of 4 7/20/17 WHI Form 348 – LILAC Leukemia Abstraction Form Ver. 1VR:\DOC\EXT2\FORMS\ALL STUDY\LILAC\CURRENT\F348V1.DOC Pg. 5 of 4 7/20/17

WHI Staging and Treatment (16156 - Activated, Traditional)

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